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Loop Formation of Meckel's Diverticulum Causing Turkish Journal of Trauma & Emergency Surgery Ulus Travma Acil Cerrahi Derg 2011;17 (6):567-569 Case Report Olgu Sunumu doi: 10.5505/tjtes.2011.54533 Loop formation of Meckel’s diverticulum causing small bowel obstruction in adults: report of two cases Erişkinlerde ince bağırsak tıkanıklığına neden olan Meckel divertikülüne bağlı halka oluşumu: İki olgu sunumu Shilpi SINGH GUPTA, Onkar SINGH Meckel’s diverticulum is the most common congenital anom- Meckel divertikülü olguların çoğunluğunda asemptomatik aly of the gastrointestinal tract, and in the majority of cases olarak kalan en yaygın konjenital gastrointestinal sistem it remains asymptomatic. The total lifetime rate of complica- anomalisidir. Yaşam boyu komplikasyon oranı %4’dür. tions is 4%. It is an uncommon cause of intestinal obstruction Erişkinlerde nadir bir intestinal tıkanıklık nedenidir. İnce in adults. Loop formation of Meckel’s diverticulum leading bağırsak tıkanıklığına neden olan Meckel divertikülüne to small bowel obstruction is an extremely rare event. We ilişkin halka oluşumu oldukça enderdir. Biz, Meckel di- report two such cases in which the bowel became obstructed vertikülünün distal ucu ile proksimal ileum ve mezenter and strangulated in a loop formed by adhesion of the distal arasında halka şeklinde adezyonlar oluşmasıyla bağırsa- end of the Meckel’s diverticulum to the proximal ileum and ğın tıkandığı ve strangülasyona uğradığı iki olguyu sunu- mesentery. yoruz. Key Words: Adults; intestinal obstruction; Meckel’s diverticu- Anahtar Sözcükler: Erişkinler; intestinal tıkanıklık; Meckel diver- lum. tikülü. Meckel’s diverticulum is an uncommon cause of rigidity throughout. Bowel sounds were increased. intestinal obstruction in adult life.[1] Rarely, Meckel’s Ultrasonography (USG) of the abdomen revealed hy- diverticulum may form a loop due to adhesions be- perperistaltic dilated small bowel loops. Erect radio- tween its distal end and the bowel itself or the mes- graph of the abdomen showed multiple air fluid levels entery.[2-6] Adhesion of the diverticulum to the bowel situated in the central abdomen and to the left (Fig. wall, thus creating a loop and causing obstruction, has 1). A nasogastric tube was inserted, which drained bil- been reported only twice.[5,6] Bowel loops may become ious secretion. The patient was taken for exploratory entangled in this loop and strangulated. The condition laparotomy, and a proximal ileal segment was found, is usually not suspected before exploration, but may compressed by a loop formed by adhesion of the tip of lead to gangrene of the bowel and high mortality if the the Meckel’s diverticulum to the antimesenteric bor- treatment is delayed. der of the terminal ileum (Fig. 2a). Proximal bowel CASE REPORTS loops were dilated, but fortunately not gangrenous. The Meckel’s diverticulum and adhesion were ex- Case 1- A 32-year-old male with no previous his- cised, and the small bowel freed and decompressed. tory of abdominal surgery presented with a history of The base of the diverticulum was inflamed (Fig. 2b). abdominal pain and vomiting of two days’ duration. Continuity was restored with end-to-end anastomosis. History of absolute constipation was present for one The patient made an uneventful recovery after the sur- day. There was no history of similar pain in the past. gery and was asymptomatic at the last follow-up. On examination, his vital signs were within normal limits, but signs of dehydration were present. The Case 2- A 28-year-old male presented with a his- abdomen was distended, with muscle guarding and tory of abdominal pain, vomiting and constipation of M.G.M Medical College & M.Y. Hospital, M.G.M. Tıp Koleji ve M.Y. Hastanesi, Indore, India. Indore, Hindistan. Correspondence (İletişim): Shilpi Singh Gupta, M.D. VPO-Sangowal, Tehsil-Nakodar 144041, Jalandhar, India. Tel: +91 - 7552740240 e-mail (e-posta): [email protected] 567 Ulus Travma Acil Cerrahi Derg Fig. 1. Case 1 - Erect abdominal radiograph showing mul- Fig. 3. Case 2 - Erect abdominal radiograph showing mul- tiple air-fluid levels predominantly in the central ab- tiple air-fluid levels predominantly in the central ab- domen and to the left. domen and to the left. three days’ duration. There was no history of a pre- loop with proximal dilatation. A proximal 8” segment vious similar pain or of previous surgery. The abdo- of the ileum was gangrenous. En-bloc resection of the men was distended, with tenderness and guarding gangrenous segment of bowel and Meckel’s diverticu- throughout. Total leukocyte count was 19,600/cmm. lum was performed, and continuity was maintained Renal function tests were normal. USG of the abdo- with end-to-end anastomosis. The patient had an un- men revealed hyperperistaltic dilated small bowel eventful postoperative recovery. loops with a small amount of free fluid in the abdo- men. Plain X-ray of the abdomen revealed multiple DISCUSSION air-fluid levels (Fig. 3). Exploratory laparotomy was Meckel’s diverticulum is a congenital outpouching planned. Intra-operatively, the Meckel’s diverticulum arising from the antimesenteric border of the distal il- with gangrenous base was found attached to mesen- eum that is present in 1-3% of the general population. tery by its distal end, thus forming a loop (Fig. 4). A It is a remnant of the vitellointestinal duct that con- segment of the terminal ileum was compressed in this nects the primitive gut to the yolk sac during devel- (a) (b) Fig. 2. Case 1 - (a) Obstruction of the ileal segment by a loop formed by adhesion of the tip of the Meckel’s di- verticulum to the antimesenteric border of the terminal ileum; (b) The resected specimen of the Meckel’s diverticulum. (Color figure can be viewed in the online issue, which is available at www.tjtes.org) 568 Kasım - November 2011 Loop formation of Meckel’s diverticulum be treated as an emergency condition with immediate exploratory laparotomy after initial resuscitation. The main aim of surgery is to remove the Meckel’s diver- ticulum along with resection of the gangrenous seg- ment of the bowel, if gangrene is present.[11] Recently, laparoscopy has proved useful to resolve small bowel obstruction associated with Meckel’s diverticulum.[12] Both the cases reported herein were young adult males presenting with acute colicky abdominal pain. There was no history in either patient that would have suggested any common etiology leading to acute in- testinal obstruction. In conclusion, loop formation due to adhesions between the distal end of the Meckel’s diverticulum and the intestine or the mesentery is an infrequent Fig. 4. Case 2 - The Meckel’s diverticulum with gangrenous phenomenon and is even rarer in adults. The condi- base attached to the mesentery by its distal end, thus tion requires a high degree of suspicion, and should be forming a loop. included in the differential diagnosis of small bowel (Color figure can be viewed in the online issue, which is avail- obstruction in adults. able at www.tjtes.org) REFERENCES opment. The majority of cases remain asymptomatic, 1. Nath DS, Morris TA. Small bowel obstruction in an adolescent: but complications include hemorrhage, intestinal ob- a case of Meckel’s diverticulum. Minn Med 2004;87:46-8. struction, diverticulitis, umbilical discharge, perfora- 2. Dumper J, Mackenzie S, Mitchell P, Sutherland F, Quan ML, tion, and peritonitis.[7] Only about 4% of patients with Mew D. Complications of Meckel’s diverticula in adults. Meckel’s diverticulum are symptomatic.[8] The total Can J Surg 2006;49:353-7. lifetime rate of complications is widely accepted at 3. Piñero A, Martínez-Barba E, Canteras M, Rodriguez JM, 4%, with a male-to-female ratio ranging from 1.8:1 to Castellanos G, Parrilla P. Surgical management and compli- cations of Meckel’s diverticulum in 90 patients. Eur J Surg 3:1.2 While in adults, the most common complication 2002;168:8-12. [5] is intestinal obstruction, Meckel’s diverticulum is an 4. Tomikawa M, Taomoto J, Saku M, Takeshita M, Yoshida K, infrequent cause of intestinal obstruction.[1,5] Sugimachi K. A loop formation of Meckel’s diverticulum: a Various mechanisms of small intestinal obstruction case with obstruction of the ileum. Ulus Travma Acil Cerrahi Derg 2003;9:134-6. from Meckel’s diverticulum include diverticular in- 5. Prall RT, Bannon MP, Bharucha AE. Meckel’s diverticu- tussusception, which is the most common mechanism, lum causing intestinal obstruction. Am J Gastroenterol volvulus from persistent attachment to the umbilicus, 2001;96:3426-7. congenital meso-diverticular bands, Littre’s hernias, 6. Devanaboyna G, Singh-Ranger D, Shami S. Meckel’s diver- foreign body impaction, diverticulitis, and adhesions ticulum causing mechanical small bowel obstruction. Can J or neoplasms.[2,4,9] Other very rare causes of obstruc- Surg 2008;51:156. tion from Meckel’s diverticulum include formation 7. Kusumoto H, Yoshida M, Takahashi I, Anai H, Maehara Y, of a loop between the end of a Meckel’s diverticulum Sugimachi K. Complications and diagnosis of Meckel’s di- verticulum in 776 patients. Am J Surg 1992;164:382-3. and the adjacent mesentery or bowel wall.[2-4,9] Loop 8. You JS, Chung SP, Park YS, Yu JS, Park YA. A case of stran- formation as a result of the development of adhesions gulated small bowel obstruction caused by Meckel’s diver- between the distal end of the diverticulum and the ticulum in an adult. J Emerg Med 2007;33:133-5. [2- mesentery or the bowel is an extremely rare finding. 9. Karadeniz Cakmak G, Emre AU, Tascilar O, Bektaş S, Uçan 4,10] The former finding of adhesion of the diverticulum BH, Irkorucu O, et al. Lipoma within inverted Meckel’s di- to the mesentery, thus forming a loop and leading to verticulum as a cause of recurrent partial intestinal obstruc- an obstructive case in adults, is very rarely reported; tion and hemorrhage: a case report and review of literature.
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